cms_WV: 112
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 112 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 225 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview the facility failed to thoroughly investigate the background of potential employees prior to or upon their employment at the facility. This was true for Employee # 150 who was hired by the facility on 04/10/17. As of 08/30/17 the facility had not screened Employee #150 through the West Virginia Cares Registry and Employment Screening (WV CARES) program as required by West Virginia State Code 16-49-9. This employee had access to all residents residing at the facility. Also, the facility failed to report three (3) of thirty-five (35) reportable incidents to the appropriate state agency. The facility reported these allegations to the Nursing Home Program even though a nurse aide was identified during the investigation as the alleged perpetrator therefore the allegations should have been reported to the Nurse Aide Program. These reportable incidents involved Resident #322, #372, and #280. Additionally, the facility failed to report all allegations of abuse and/or neglect to the appropriate state agencies for four (4) of fifty-five (55) complaints/concerns completed by the facility for the month of (MONTH) (YEAR). The allegations not reported involved Resident # 84, #110, #233, and #290. Finally, the facility failed to report a verbal allegation of neglect to the appropriate state agency for resident #367. Resident Identifiers: #84, #110, #233, #290, #322. #372, #280 and #367. Employee Identifier: #150. Facility Census: 180. Findings Include: a) WV CARES West Virginia Code 16-49-9 established new criminal background check requirements for applicants for employment as direct access personnel in long-term care facilities. Effective 08/01/15, all nursing home facilities were required to .prescreen all direct access personnel applicants considered for hire for negative findings by way of an Internet search of registries and licensure databases through the WV Cares website. WV CARES is administered by the Department of Health and Human Resources and the WV State Police Criminal Investigation Bureau (CIB) in consultation with the Centers for Medicare and Medicaid Services (CMS), the Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI). The program uses web-based technologies to provide employers a single portal for checking state and national abuse registries and the state and national sex offender registries. The web-based system also provides employers access to Nurse Aide Registries for all 50 states and professional licensure registries where available. The web based system provides an efficient and effective means for an employer to check an applicant's status prior to paying the cost of a criminal history background check. Through fingerprinting, this program provides a comprehensive criminal history records search of national and state criminal history records that was not available under the previous reliance on name-based record searches. The program relies on new technology to monitor criminal histories and alert officials when a subsequent change in criminal history occurs (i.e., rapback) A monitored criminal history record means the cost of re-fingerprinting is not required for employees who change employers in this industry (or apply for work at more than one employer) within the timeframe of a valid background check. All fitness determinations will be performed by WV CARES who have cleared state and federal background check requirements. Employers will receive a notice of the applicants employment eligibility once the fingerprint based background check results are received. At 8:48 a.m. on 08/30/17 a Notification of Eligible Fitness Determination letter from WV Cares was requested for Employee #150 who was hired in the dietary department on 04/10/17. At 11:47 a.m. on 08/30/17 Employee #183, the area human resource manager, stated that they did not have a WV Cares Notification of Eligible Fitness Determination letter for Employee #150. She stated that she was finger printed on 04/05/17 by MorphoTrust but that the results were never sent to WV Cares. She indicated she did not realize that they had not been sent to WV CARES until she went to pull it from the WV CARES system when it was requested by the surveyor on 08/30/17. b) Resident #322 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 07/27/17 listing Resident #322 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was hand written: (typed at written) Resident alleges (unidentified) CNA (Certified Nursing Assistant) is rude, yells, and cusses at him and he alleges this CNA told him that they were not going to change him every 2 (two) hours. Review of the five - day follow up pertaining to this allegation completed by Licensed Practical Nurse (LPN) Social Service Manager (SSM) #15 found the following: (typed as written) I spoke with the resident and he told me that the CNA was (first name of Nurse Aide (NA) #13) . I spoke with the CNA (first and last name of NA #13) who told me she recall the evening and stated in fact the resident was the one who was cussing and screaming and she stated she immediately went out and told the co worker what had happened. During an interview with LPN - SSM #15 beginning at 3:35 p.m. on 08/30/17 in regards to this allegation she stated this was not reported to the Nurse Aide Program after a Nurse Aide was identified because she spoke with Resident #322 and he had stated the NA just needed to be fine tuned and therefore she did not feel it was substantiated so she did not report it to the Nurse Aide Program. c) Resident #372 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 08/01/17 listing Resident #372 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was typed: (typed as written) The residents son alleges the following: Resident has had a decline in status and wont do anything, call light not answered timely, alleges waited 3 1/2 hours to be changed after a bowel movement and pain medication it not effective enough. Review of the five - day follow up pertaining to this allegation completed by LPN - SSM #15 found the following: (typed as written) . In regards to allegation of having a bowel movement and waiting 3 hours to be changed. he states this was Saturday into Sunday from 4:30 a.m. to 8:00 a.m During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if once the resident gave her a specific time frame if she reported the Nurse Aide who was assigned to him during this time frame to the Nurse Aide Program as an alleged perpetrator she stated, No because the allegation was not substantiated therefore I did not report it to the Nurse Aide Program. She further stated, Maybe I should have done that. d) Resident #280 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 07/26/17 listing Resident #280 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was hand written: (typed as written) Resident alleged CNA took her to the shower room and during the time in the shower alleges CNA left shower and told her she had to get another resident off the bedpan - states CNA was gone less than five minutes and no issues occurred . Review of the five - day follow up pertaining to this allegation completed by LPN - SSM #15 found the following: (typed as written) After interviewing the resident, it was found the date she is alleging was 07/17/17. It was also found out that the CNA was (First and Last Name of NA #145). I spoke with (First Name of NA #145) regarding this allegation and she reports she does remember this day and she took the resident to the shower and it was very hot in the shower room. She stated that (First name of Resident #280) was safely in her chair and she told the resident she was going to open the first door to the shower room to catch her breath and she would be able to hear her (stating it was just a few feet away) During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if once the Nurse Aide was identified if this allegation was then reported to the Nurse Aide Program she stated, No it was not, because it was unsubstantiated so I did not think to report it. e) Resident #84 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 06/19/17 which identified Resident #84 as the Resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Daughter states he did not get shower, toothbrush or water pitcher from Saturday until Wednesday. Feels like they left him up too long in his wheelchair on Wednesday. Review of the reportable incidents for the month (MONTH) (YEAR) found no reportable incident related to concern voiced by Resident #84's daughter. During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if this allegation was reported as an allegation of neglect she stated, No because I pulled the ADL (Activities of Daily Living) flow sheet report immediately and the daughter was fine with that. f) Resident #110 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/15/17 which identified Resident #110 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Resident stated she had been asking since lunch time to be cleaned up. Went into room at 3:45 p.m. to change dressing and resident voiced concern about not being cleaned. CNA went into room to clean up resident at this time. Resident states this is not the first time. Resident room partner stated yellow ring around the residents sheet. Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to concern voiced by Resident #110. An interview with the Nursing Home Administrator (NHA) at 4:21 p.m. on 08/30/17, confirmed he was the person who handled this concern for Resident #110. When asked if this concern had been reported as an allegation of neglect he stated, No because after doing further interviews he did not feel like it was a reportable incident. g) Resident #233 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/17/17 which identified Resident #233 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Resident reports that the weekend was terrible and her got into an argument with RCS - (First name of RCS) on 4 occasions. Reports a very bad attitude - that she put him down on Saturday as refusing a bath and he did not refuse. She would not make his bed how he asked her too. She fuss with me every time she to come into my room. My roommate laid in a dirt brief from breakfast to noon yesterday. They would come in and turn light off and would not change him. Finally around noon he got changed. Last night (Sunday after Midnight) I put my call light on and it took 40 minutes to get someone in here. Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to this concern voiced by Resident #233. An interview with the NHA at 4:11 p.m. on 08/30/17 confirmed this concern was not reported as an allegation of abuse and/or neglect. He indicated after he finished up his investigation he did not feel it was substantiated therefore he did not report it. h) Resident #290 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/16/17 which identified Resident #290 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Husband states nurse forced her to take medicine, among other issues. Wants to talk to administrator . Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to this concern voiced by Resident #290. An interview with the NHA at 4:19 p.m. on 08/30/17, confirmed this allegation of abuse was not reported. He stated that after he talked to Resident #290's husband it was clear the nurse was just adamant that the resident take her medicine and she did not force her to take it. He indicated that is why he did not report this allegation of abuse. i) Resident #367 On 08/29/17 at 11:14 a.m., during a Stage 1 interview of the QIS survey, Resident #96 said a female resident across the hall from him had yelled for 30 minutes needing a bed pan. Resident #96 did not know if the other resident's call light was on. Resident #96 also did not know if this resident ever received assistance. During an interview with Administrator #107, on 09/07/17 at 10:38 am., he said he did have knowledge of this issue and had spoken with Resident #96 and had identified Resident #367 as the resident who needed assistance. During the interview, on 09/07/17 at 10:38 a.m., Administrator #107 provided hand written notes dated 08/21/17. The notes reflect Administrator #107's conversation with Resident #96 and Resident #367. Resident #367 was identified as having a [DIAGNOSES REDACTED].#107's conversation with Resident #367 the resident denied having any issues with needing a bedpan the night before. The administrator noted the resident had a catheter, was on a toileting plan and was care planned for yelling out and turning call light on continuously. Administrator #107 said he had not interviewed any staff regarding this issue nor had he identified this as an allegation of neglect. He also confirmed he had not reported this issue to the appropriate outside State agencies. He said he did not report this issue because after speaking with the resident and obtaining information from other sources he concluded the resident had not been neglected. j) Policy Review A review of the facility's Abuse and Neglect Prohibition Policy with revision date of (MONTH) (YEAR), on 08/30/17 at 9:00 a.m., found the following under the section titled Reporting and Response: 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and Adult Protective Services (where state law provides for jurisdiction in long term care facilities) in accordance with state law through established procedures. Timeline for reporting is as follows: a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made no later than 2 hours after the management staff becomes aware of allegation. b. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury a report is made not later than 24 hours after the management team become aware of the allegation 3. The facility will report any occurrences of abuse by licensed or certified staff and any knowledge it has of actions by a court of law against an employee , which would indicate unfitness for employment to the applicable state board in accordance with the state law. | 2020-09-01 |